Complete this form if you believe you are the heir to property held by the Nevada
Unclaimed Property Division. Do not complete this form if the decedent’s estate went
through probate in court, if there has been some other type of court determination OR
if you are the surviving spouse.
1. Please complete all fields:
Decedent’s Name: Date of Death:
Your Name: Your Relationship to Decedent:
Was Decedent Married at Time of Death? Yes / No
Decedent’s Spouse at Time of Death:
Spouse’s Date of Death (If Applicable):
2. Provide information on all of the decedents natural born and adopted children only, both living and deceased:
(If none, please write “none” - This section cannot be blank)
Child’s Name Birth Date Date of
Death (If
If Deceased, Does Deceased
Child have Children (Circle
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
3. Provide information on the decedent’s grandchildren, born only to the deceased children indicated in section 2
(If none, please write “none”)
Grandchild’s Name Birth Date Name of Deceased Parent
4. If the decedent has no living children or grandchildren, please complete this section:
Date of Death (if applicable):
Date of Death (if applicable):
5. If the decedent has no living children, grandchildren or parents, please complete this section on decedent’s
siblings (living and deceased):
Birth Date
Date of
Does Deceased Sibling
Have Children
Yes / No
Yes / No
Yes / No
6. Provide information on the decedent’s nieces and nephews born only to the deceased siblings indicated in
section 5 (if none, please write “none”):
Name of Deceased Parent
You may use an attachment if additional space is required. Please indicate which section the additional
information belongs with.
The affiant acknowledges that he/she understands that filing a false affidavit constitutes a felony in this state.
I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct.
EXECUTED this day of , 20 .
(Affia nt )
Notary Signature:_________________________
Commission Expires:_______________________